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CPT 21930? Please help!

  1. Default CPT 21930? Please help!
    Medical Coding Books
    Need help with the following: Doc wants to use CPT 21930 but I'm not too sure this is correct. Thanks!!!

    DX: Infected sebaceous cyst in the right back
    1.Culture from the cyst.
    2. Sebaceous cyst in its entirety

    FINDINGS:Infected cyst.
    INDICATIONS:The patient is a 38‑year‑old gentleman who presented to my office with a right back cyst that was tender and increasing in size. I explained the risks and benefits of the procedure and he gave me his full consent.

    OPERATIVE PROCEDURE:He was brought to the operating room where timeout was performed to myself. Anesthesia and nursing teams confirmed the appropriate patient and procedure. Clindamycin was given 30 minutes prior to induction. Conscious sedation was given. The patient also received local sedation. The patient was placed prone. The right back was prepped and draped in normal sterile fashion. I anesthetized the area with 30 mL of local anesthetic.
    I made a transverse incision approximately 3 cm over the area. Immediately, I removed approximately 10 or 15 mL of pus and this was cultured. I then resected the entire cyst cavity. It was quite deep and extended toward the muscle fascia, but I do not believe it adhered to the the muscle fascia. I enucleated the entire area with copious amounts of irrigation. I achieved hemostasis. I then closed the deep dermal layers with 2‑0 Vicryl. I then closed the skin with 2‑0 Vicryl mattress sutures. Bacitracin was applied to the skin.

  2. #2
    Columbia, MO
    What code are you suggesting instead?

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    21932 maybe... because it extends to the muscle fascia. and what also confused me what the drainage of pus.... and path report coming back stating inflamed epidermoid cyst

  4. Default
    I believe I would go with 21932....

  5. Default
    I actually just noticed something......after reading it again... it actually didn't "adhere to the muscle" so now I'm actually thinking 21930?

  6. Default
    To me, I still think he was at muscle, he must have visualized it to know whether or not it was adhering...

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